Method for egfr directed combination treatment of cancer

ABSTRACT

The present invention relates to a method of treating patients suffering from cancers driven by deregulated Human Epidermal Growth Factor Receptor (HER/Human EGFR), wherein an irreversible tyrosine kinase inhibitor (TKI) is administered according to a continuous regimen based on an average daily dose in the range of 10 to 50 mg and the mAB is co-administered according to a dosing regimen ranging from an average weekly iv dose of 50 to 500 mg/m 2  repeated thrice, twice or once a week, once in two weeks, once in three weeks or at least monthly to a patient in need of such treatment.

The present invention relates to a method of treating patients sufferingfrom cancers driven by deregulated Human Epidermal Growth FactorReceptor (HER/Human EGFR) such as, but not limited to, non-small celllung cancer (NSCLC), head and neck squamous cell carcinoma (HNSCC),breast cancer, esophageal cancer, gastric cancer, renal cancer, cervicalcancer, ovarian cancer, pancreatic cancer, hepatocellular cancer,malignant glioma, prostate cancer and colorectal cancer (CRC) comprisinga flexible and active regimen for combining an irreversible tyrosinekinase inhibitor (TKI) and a Human EGFR targeted monoclonal antibody(mAB), wherein in this method the TKI is administered according to acontinuous regimen based on an average daily dose in the range of 10 to50 mg and the mAB is co-administered according to a dosing regimenranging from an average weekly intravenous (iv) dose of 50 to 500 mg/m²repeated thrice, twice or once a week, once in two weeks, once in threeweeks or at least monthly to a patient in need of such treatment. Themethod of treatment of the invention includes treatment of TKI naivepatients as well as of patients pretreated with EGFR TKIs, particularlythose patients with primary or acquired resistance to treatment withreversible or irreversible TKIs such as gefitinib, erlotinib,1-(4-(4-(3,4-dichloro-2-fluorophenylamino)-7-methoxyquinazolin-6-yloxy)piperidin-1-yl)prop-2-en-1-one,or salts thereof, EKB-569 (pelitinib), HKI-272 (neratinib), HKI-357,lapatinib, CI-1033 (canertinib), WZ 3146, WZ 4002, WZ 8040 (structuresof the three WZ compounds disclosed by Wenjun Zhou et al.: Novelmutant-selective EGFR kinase inhibitors against EGFR T790M, in Nature2009, Vol. 462, 1070-1074), Icotinib, BIBW 2992 or PF-00299804(dacomitinib). Furthermore the method of treatment of the inventionincludes to overcome primary or acquired resistance and prevention ordelay of acquired resistance to treatment with (reversible orirreversible) TKIs.

Additional aspects of the invention are pharmaceutical compositions andpharmaceutical kits which include instructions for coadministration ofthe TKI with the mAB, irreversible TKIs for coadministration with atargeted mAB that prevents the binding of ligands to EGFR and the use ofan irreversible TKI for preparation of a pharmaceutical compositioncomprising an effective amount of the irreversible TKI, together with aninstruction for coadministration with the mAB.

BACKGROUND OF THE INVENTION

EGFR is expressed in several solid malignancies, including NSCLC, HNSCC,malignant glioma and colorectal cancer, and abnormal or deregulated EGFRactivity is known to contribute to numerous tumorigenic processes. Lungcancer remains the leading cause of cancer death in industrializedcountries. Cancers that begin in the lungs are divided into two majortypes, non-small cell lung cancer and small cell lung cancer, dependingon how the cells appear under a microscope. Non-small cell lung cancer(squamous cell carcinoma, adenocarcinoma, and large cell carcinoma)generally spreads to other organs more slowly than does small cell lungcancer. About 75 percent of lung cancer cases are categorized asnon-small cell lung cancer (e.g., adenocarcinomas), and the other 25percent are small cell lung cancer. For patients with advanced disease,chemotherapy provides a modest benefit in survival, but at the cost ofsignificant toxicity, underscoring the need for therapeutic agents thatare specifically targeted to the critical genetic lesions that directtumor growth (Schiller J H et al., N Engl J Med, 346: 92-98, 2002).

Mutations that lead to EGFR overexpression (known as upregulation) oroveractivity have been associated with a number of cancers, includinglung cancer, anal cancers and glioblastoma multiforme. Mutations,amplifications or misregulations of EGFR or family members areimplicated in about 30% of all epithelial cancers. Consequently,mutations of EGFR have been identified in several types of cancer, andhas led to the development of anticancer therapeutics directed againstEGFR, using two approaches: (1) targeted monoclonal antibodies (mABs)that prevent the binding of ligands to EGFR, and (2) small moleculetyrosine kinase inhibitors (TKIs) that block the intracellular catalyticactivity of the receptor. Skin toxicity characterized by rash oracne-like symptoms and diarrhea of different grades are the most commonadverse events of EGFR targeted therapies (Expert Opin. Investig. Drugs(2009) 18(3), 293-300).

The human/mouse chimeric IgG1 mAb cetuximab down-regulates EGFRsignaling and subsequently inhibits cell proliferation, inducesapoptosis and reduces angiogenesis. Cetuximab in combination withchemotherapy has been approved by Health Authorities for the treatmentof metastatic colorectal cancer and for the treatment of locallyadvanced and metastatic head and neck cancer. Cetuximab has alsodemonstrated little clinical activity as a single agent in patients withadvanced NSCLC after prior EGFR TKI therapy (Neal J W, Heist R S, FidiasP, Temel J S, Huberman M, Marcoux J P, Muzikansky A, Lynch T J, SequistL V; J Thorac Oncol. 2010 November; 5(11):1855-8: Cetuximab monotherapyin patients with advanced non-small cell lung cancer after priorepidermal growth factor receptor tyrosine kinase inhibitor therapy).Panitumumab (VECTIBIX®) is a human IgG2 mAB against EGFR and approvedfor treatment of metastatic colorectal cancer. Other monoclonals inclinical development are zalutumumab, nimotuzumab, matuzumab andnecitumumab.

First generation small molecule HER TKIs include gefitinib (Iressa®) anderlotinib (Tarceva®), both binding reversibly to the EGFR. Gefitinib isindicated in all lines of treatment of advanced NSCLC harbouring EGFRmutations in the tumor and erlotinib is indicated as treatment ofadvanced NSCLC after prior chemotherapy, but in development in all linesof EGFR mutation positive NSCLC These new drugs directly target theEGFR. Patients have been divided into EGFR positive (EGFR⁺) and negative(EGFR⁻), based upon whether a tissue test shows a mutation. EGFRpositive patients with tumors harboring EGFR mutations in exons 19 and21 associated with drug sensitivity (i.e., G719X, exon 19 deletion,L858R, L861Q) have shown an response rate up to 60% which exceeds theresponse rate for conventional chemotherapy.

Second generation small molecule TKIs have been designed as irreversibleEGFR inhibitors which bind irreversibly to EGFR, preferably to cysteine773 of EGFR. Nonlimiting examples include compounds disclosed in U.S.Pat. No. 6,002,008, U.S. Pat. No. 7,019,012, U.S. Pat. No. 6,251,912, WO02/50043, WO 2004/074263, WO 2005/037824, WO 2008150118 (specificallythe compound of Example 36,1-(4-(4-(3,4-dichloro-2-fluorophenylamino)-7-methoxyquinazolin-6-yloxy)piperidin-1-yl)prop-2-en-1-one,or salts thereof formed with acidic additives as disclosed in WO2011155793), EKB-569 (pelitinib), HKI-272 (neratinib), HKI-357, CI-1033(canertinib), WZ 3146, WZ 4002, WZ 8040 (structures of the three WZcompounds disclosed by Wenjun Zhou et al.: Novel mutant-selective EGFRkinase inhibitors against EGFR T790M, in Nature 2009, Vol. 462,1070-1074), BIBW 2992 or PF-00299804. BIBW 2992 (afatinib) andPF-00299804 (dacomitinib) are most advanced second generation smallmolecule TKIs include, both in advanced clinical development fortreatment of NSCLC.

More specifically, BIBW 2992, also referred to herein by it's INNafatinib, is known as the compound4-[(3-chloro-4-fluorophenyl)amino]-6-{[4-(N,N-dimethylamino)-1-oxo-2-buten-1-yl]amino}-7-((S)-tetrahydrofuran-3-yloxy)-quinazoline,

preferably used as a maleate salt BIBW 2992: maleic acid 1:2:

BIBW 2992 is a potent irreversible and selective dual inhibitor of erbb1receptor (EGFR) and erbB2 (Her2/neu) and erbB4 (Her4) receptor tyrosinekinases which can be administered orally. Furthermore, BIBW 2992 wasdesigned to covalently bind to EGFR and HER2 thereby irreversiblyinactivating the receptor molecule it has bound to. This compound, saltsthereof such as the dimaleate salt, their preparation as well aspharmaceutical formulations comprising BIBW 2992 or a salt thereof,indications to be treated with BIBW 2992 and combinations including BIBW2992 are disclosed in WO 02/50043, WO 2005/037824, WO 2007/054550, WO2007/054551, WO 2008034776 and WO 2009147238.

PF-00299804 is an oral irreversible pan-HER TKI, more specifically aninhibitor of the HER1, 2, and 4 tyrosine kinases. In preclinicalstudies, PF-00299804 has been shown to inhibit the signaling in bothwild-type and mutant EGFR, including forms of NSCLC that are resistantto currently available EGFR inhibitors, such as erlotinib and gefitinib.Preclinical findings suggest that PF-00299804 may be clinicallyeffective against NSCLCs with EGFR or ERB-B2 mutations as well as thoseharboring the EGFR T790M mutation, which produces resistance togefitinib and erlotinib (Expert Opin. Investig. Drugs (2010) 19(12):1503-1514). PF-00299804 (dacomitinib) is the compoundN-[4-(3-chloro-4-fluoro-phenylamino)-7-methoxy-quinazoline-6-yl]-3-piperidin-l-yl-acrylamide,disclosed in WO 2005107758 as Examples 2 and 3 with the followingstructure:

Characteristics of EKB-569 (pelitinib), HKI-272 (neratinib), HKI-357 andCI-1033 are published, e.g. Expert Opin. Investig. Drugs 2009, 18(3),293-301 provides a review. Development of EKB-569 for treatment of NSCLChas been discontinued several years ago. Others report that HKI-272 canovercome T790M-mediated resistance only at suprapharmacologicconcentrations (N. Godin-Heymann et al., The T790M “gatekeeper” mutationin EGFR mediates resistance to low concentrations of an irreversibleEGFR inhibitor. Mol. Cancer Ther. 7, 2008:874-879). Remarkably,development of HKI-272 for treatment of NSCLC was discontinued afterphase II trial showed that the compound had low activity in patientswith prior benefit from TKIs and in TKI-naive patients, potentiallybecause of insufficient bioavailability from diarrhea-imposed doselimitation (L. V. Sequist et al., J. Clin . Onc. 28 (18), 2010,3076-3083). In contrast to encouraging preclinical results and highpotency of HKI-272 these did not translate into clinical benefit,showing the low level of predictability in this field.

Despite initial response in NSCLC patients with EGFR mutations, acquiredresistance develops after a median of approximately 12 months. Theconsensus definition of acquired resistance includes patients who hadprevious treatment with a single-agent EGFR-TKI (e.g., gefitinib orerlotinib); either or both of the following: a tumor that harbors anEGFR mutation known to be associated with drug sensitivity (i.e., G719X,exon 19 deletion, L858R, L861Q) or objective clinical benefit fromtreatment with an EGFR-TKI; systemic progression of disease applyingRECIST criteria known in the art, while on continuous treatment withEGFR directed treatment for at least 24 weeks.

Response evaluation criteria in solid tumours (RECIST) are described byP. Therasse et al., J Natl Cancer Inst 2000, 92, 205-216; in J. Clin.Oncol. Vol 24, No. 20, 2006, pp 3245-3251; or by Eisenhauer EA, TherasseP, Bogaerts J, Schwartz L H, Sargent D, Ford R, et al., New responseevaluation criteria in solid tumours: revised RECIST guideline (version1.1). Eur J Cancer 2009; 45:228-247. Monitoring tumor progression may bedetermined by comparison of tumor status between time points aftertreatment has commenced or by comparison of tumor status between a timepoint after treatment has commenced to a time point prior to initiationof treatment. Tumor progression may be monitored during treatmentvisually, for example, by means of radiography, for example, X-ray, CTscan, or other monitoring methods known to the skilled artisan,including palpitation of the cancer or methods to monitor tumorbiomarker levels.

In addition to the primary EGFR mutations (associated with erlotinib andgefitinib sensitivity), approximately half of the patients with acquiredEGFR-TKI resistance have a second EGFR mutation (T790M) in theATP-binding pocket of the tyrosine kinase that may alter receptoraffinity in favor of ATP. These second mutations enable the cancer cellsto continue signaling via mutant EGFR, suggesting that in a proportionof patients with acquired resistance to EGFR-TKIs, tumor growth andproliferation remains dependent on EGFR.

The presence of MET oncogene has been reported as a second sources ofresistance (Jackman D, Pao W, Riely G J, Engelman J A, Kris M G, Janne PA et al., Clinical definition of acquired resistance to epidermal growthfactor receptor tyrosine kinase inhibitors in non-small-cell lungcancer, J Clin Oncol 2010; 28:357-60).

As of 2010 there was no clinical consensus of an accepted approach toovercome or prevent resistance nor regulatory approval of a specificdrug or drug combination in this setting.

There is a significant medical need in the art for a satisfactorytreatment of cancer, and specifically epithelial cell cancers such aslung, ovarian, breast, brain, colon and prostate cancers, whichincorporates the benefits of EGFR targeted therapy and overcoming thenon-responsiveness exhibited by patients' cancers. Thus, the problemunderlying the present invention is to establish an improved treatmentof patients suffering from epithelial cell cancers, characterized byimproved efficacy and improved or at least acceptable tolerability,including the following patient populations

-   -   (a) TKI naive cancer patients, wherein the improvement includes        prevention or delay of resistance to TKI treatment,    -   (b) patients with tumors expressing the wild-type EGFR        (described hereinbefore as    -   (c) patients with tumors expressing mutated forms of the EGFR        (described hereinbefore as EGFR⁺),    -   (d) patients previously treated with EGFR inhibitors, such as        gefitinib or erlotinib afatinib, dacomitinib or others wherein        the improvement includes to overcome primary or acquired        resistance to EGFR inhibitors,    -   (e) patients with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the improvement includes to overcome resistance to TKI        treatment,    -   (g) patient populations with primary or acquired resistance        caused by T790M (T790M+), wherein the improvement includes to        prevent/overcome resistance to TKI treatment, and    -   (h) patient populations with primary or acquired resistance not        caused by T790M

(T790M-), e.g. by other mechanisms such as MET oncogene or by unknownorigin, wherein the improvement includes to to prevent/overcomeresistance to TKI treatment.

One approach to improve treatment options of NSCLC patients withacquired resistance to gefitinib or erlotinib followed the concept oftotal receptor blockade by combining a TKI and an anti-EGFR mAB. This issummarized by S. Ramalingam et al., Journal of Thoracic Oncology Vol. 3,Number 3, March 2008, 258-265. The hypothesis was that by thecombination it may be possible to achieve simultaneous verticalinhibition of EGFR and enhance abrogation of downstream activity.Residual EGFR activity after exposure to either class of inhibitor alonemay allow cancer cells to remain viable, but simultaneous dualinhibition may cause apoptosis. Results in xenograft models support thishypothesis: a synergistic effect has been observed when cetuximab isadministered in combination with erlotinib or gefitinib compared withtreatment with either agent alone. Cetuximab has been shown todown-regulate EGFR on the cellular surface, potentially enhancing thesensitivity to TKIs. The conclusion was that the combination ofcetuximab plus erlotinib seems synergistic in terms of apoptoticactivity in vitro, and results in additive tumor growth inhibition invivo.

Nevertheless, the question is whether these primary results translate inclinical benefit. S. Ramalingam et al. report the results of a phase Istudy carried out to determine the optimal doses of cetuximab andgefitinib when administered as a combination for patients withadvanced/metastatic non-small cell lung cancer (NSCLC) previouslytreated with platinum-based chemotherapy. Patients withadvanced/metastatic NSCLC treated with prior platinum-based chemotherapyreceived escalating doses of weekly cetuximab (100, 200, and 250 mg/m²,iv) and fixed doses of gefitinib (250 mg/d, PO) until diseaseprogression or unacceptable toxicity. The results reported show that thecombination of cetuximab and gefitinib can be safely administered buthas only modest activity in advanced/metastatic NSCLC.

Y. Y. Janjigian et al., Clin Cancer Res 2011, 17: 2521-2527, reportabout a phase I/II trial of cetuximab and erlotinib enrolling 19patients with lung adenocarcinoma and acquired resistance to erlotinib.Patients with lung adenocarcinoma and clinically defined acquiredresistance to erlotinib were treated with erlotinib 100 mg daily, alongwith cetuximab every 2 weeks in three escalating dose cohorts (250mg/m², 375 mg/m², and 500 mg/m²). The recommended phase II dose was thenevaluated in a two-stage trial, with a primary end point of objectiveresponse rate. The recommended phase II dose identified was cetuximab500 mg/m² every 2 weeks and erlotinib 100 mg daily. At this dose andschedule, no radiographic responses were seen. In fact, combined EGFRinhibition, with cetuximab 500 mg/m² every 2 weeks and erlotinib 100 mgdaily, had no significant activity in patients with acquired resistanceto erlotinib. During the phase II portion of the trial serioustolerability issues occurred. Common grade 2, 3 and 4 toxicities wererash (13 patients, 68%), fatigue (12 patients, 63%) and hypomagnesemia(14 patients, 74%). 31% (6 of 19 patients) discontinued treatment due tointolerable rash.

Both, S. Ramalingam et al. and Y. Y. Janjigian et al., report clinicalresults obtained with the combination of cetuximab with a reversible(first generation) TKI. In contrast, L. Regales et al., J. Clin. Invest.119 (10), 2009: 3000-3010, report results obtained with the irreversible(second generation) TKI BIBW 2992 in transgenic mouse lung tumor modelsthat develop lung adenocarcinomas driven by EGFR^(L858R) (sensitive toerlotinib), EGFR^(T790M) (resistant to erlotinib), or EGFRL858R+T790M(resistant to erlotinib) with a focus to evaluate strategies to overcomethe most common EGFR TKI resistance mutation, T790M. Other agentsmentioned in the investigation were HKI-272 (neratinib) and PF-00299804,but without reporting results. The rationale behind was that preclinicalstudies published by others (E. L. Kwak, et al., Irreversible inhibitorsof the EGF receptor may circumvent acquired resistance to gefitinib.Proc. Natl. Acad. Sci. U. S. A. 2005, 102:7665-7670; T. A. Carter etal., Inhibition of drug-resistant mutants of ABL, KIT and EGF receptorkinases. Proc. Natl. Acad. Sci. U. S. A. 2005, 102:11011-11016)suggested that second-generation irreversible EGFR inhibitors may beable to overcome T790M-mediated resistance, at least in vitro. Micebearing tumors harboring EGFR mutations were treated with a variety ofanticancer agents, including the irreversible EGFR TKI BIBW 2992 and theEGFR-specific antibody cetuximab. It was found that only the combinationof both agents together induced dramatic shrinkage oferlotinib-resistant tumors harboring the T790M mutation.

An open label phase I clinical trial of continuous once daily oraltreatment using BIBW 2992 in combination with cetuximab with the primaryobjective to determine the maximum tolerated dose (MTD) and recommendedphase II doses in patients with NSCLC and acquired resistance toerlotinib or gefitinib was disclosed in ClinicalTrials.gov at thepriority filing date of the subject patent application, identifierNCT01090011, including the history of changes available via a link toClinicalTrials.gov archive site .The following qualitative informationabout the administration regimen was publicly available:

-   -   patients to receive medium BIBW 2992 once daily plus biweekly        cetuximab infusion at low, median and high dose level    -   BIBW 2992 medium dose plus three dose levels (low, medium and        high) of cetuximab.

Results or absolute dosages were not disclosed.

SUMMARY OF THE INVENTION

A first object of the present invention is a method of treating patientssuffering from cancers driven by deregulated Human Epidermal GrowthFactor Receptor (HER/Human EGFR) comprising administering to a patientin need of such treatment a flexible and active regimen for combining anirreversible tyrosine kinase inhibitor (TKI) and a Human EGFR targetedmonoclonal antibody (mAB), wherein in this method the TKI isadministered according to a continuous regimen based on an average dailydose in the range of 10 to 50 mg and the mAB is co-administeredaccording to a dosing regimen ranging from an average weekly iv dose of50 to 500 mg/m² repeated thrice, twice or once a week, once in twoweeks, once in three weeks or at least once monthly.

A second object of the invention is a pharmaceutical kit, comprising afirst compartment which comprises an effective amount of a Human EGFRtargeted mAB and a second compartment which comprises an effectiveamount of an irreversible TKI.

A third object of the invention is an irreversible TKI for use in amethod of treatment of a patient suffering from a cancer driven byderegulated Human Epidermal Growth Factor Receptor (HER/Human EGFR) bycoadministration with a Human EGFR targeted mAB, wherein the TKI isadministered according to a continuous regimen based on an average dailydose in the range of 10 to 50 mg and the mAB is co-administeredaccording to a dosing regimen ranging from an average weekly iv dose of50 to 500 mg/m² repeated thrice, twice or once a week, once in twoweeks, once in three weeks or at least once monthly to a patient in needof such treatment.

A fourth object of the invention is the use of an irreversible TKI forpreparation of a pharmaceutical kit for treatment of patients sufferingfrom cancers driven by deregulated Human Epidermal Growth FactorReceptor (HER/Human EGFR), comprising a first compartment whichcomprises an effective amount of a Human EGFR targeted mAB and a secondcompartment which comprises an effective amount of an irreversible TKI,wherein the TKI is to be administered according to a continuous regimenbased on an average daily dose in the range of 10 to 50 mg and the mABis to be co-administered according to a dosing regimen ranging from anaverage weekly iv dose of 50 to 500 mg/m² repeated thrice, twice or oncea week, once in two weeks, once in three weeks or at least once monthlyto a patient in need of such treatment.

DETAILED DESCRIPTION OF THE INVENTION

Supported by clinical results it has surprisingly been found that thecombination of an irreversible TKI with Human EGFR targeted mAB hassignificantly more activity than may have been expected, based on theresults reported in the prior art, i.e. that dual targeting ofgefitinib/cetuximab or erlotinib/cetuximab is not active for treatmentof patients with lung adenocarcinoma and acquired resistance toreversible TKIs, as well as in view of the low tolerability reported forsuch combinations or based on preclinical data.

The irreversible TKI and the mAB can be combined with good tolerabilityat the recommended doses of the individual drugs—which was not expectedin view of the low activity and tolerability of the gefitinib/cetuximabor erlotinib/cetuximab combination reported by S. Ramalingam et al.,Journal of Thoracic Oncology Vol. 3, Number 3, March 2008, 258-265 andby Y. Y. Janjigian et al., Clin Cancer Res 2011, 17: 2521-2527,summarized hereinbefore.

Clinical trial data support that the the activity of the combinationsaccording to the invention is NOT restricted to T790M mediatedresistance to TKI treatment, i.e. not only overcomes T790M mediated(T790M+: tumor harboring T790M) acquired resistance to TKI treatment butalso acquired resistance not caused by T790M (T790M-: tumor notharboring T790M), e.g. acquired resistance caused by other mechanismssuch as MET oncogene or by unknown origin. There is no evidence in theprior art indicating that this may be the case.

These findings suggest that the combination treatment according to theinvention has the potential for significant improvement of thetherapeutic index for EGFR directed treatments of cancers driven byderegulated Human Epidermal Growth Factor Receptor (HER/Human EGFR),e.g. epithelial cell cancers. Any of these findings are supported byclinical results obtained with the combination of BIBW 2992 withcetuximab.

Patients suffering from cancers driven by deregulated Human EpidermalGrowth Factor Receptor (HER/Human EGFR) include, without limitation,patients suffering from non-small cell lung cancer (NSCLC), head andneck squamous cell carcinoma (HNSCC), malignant glioma, breast cancer,esophageal cancer, gastric cancer, renal cancer, cervical cancer,prostate cancer, ovarian cancer, pancreatic cancer, hepatocellularcancer, and colorectal cancer (CRC), including metastatic forms thereof.Preferred indications are NSCLC and HNSCC, especially NSCLC.

Furthermore, patients having one of cancer indications specifiedhereinbefore which may advantageously be treated by the method of theinvention include the following patient populations:

-   -   (a) TKI naive cancer patients, wherein the treatment provides        prevention or delay of resistance to TKI treatment,    -   (b) patients with tumors expressing the wild-type EGFR,    -   (c) patients with tumors expressing mutated forms of the EGFR,    -   (d) patients previously treated with EGFR inhibitors, such as        gefitinib or erlotinib afatinib, dacomitinib or others wherein        the treatment provides to overcome primary or acquired        resistance to EGFR inhibitors    -   (e) patients with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the treatment provides to overcome resistance to TKI        treatment,    -   (g) patient populations with primary or acquired resistance        caused by T790M (T790M+), wherein the i treatment provides to        prevent or overcome resistance to TKI treatment, and    -   (h) patient populations with primary or acquired resistance not        caused by T790M (T790M-), e.g. by other mechanisms such as MET        oncogene or by unknown origin, wherein the treatment provides to        prevent or overcome resistance to TKI treatment.

Preferably, the following patient populations having one of the cancerindications specified hereinbefore may advantageously be treated by themethod of the invention:

-   -   (c) patients with tumors expressing mutated forms of the EGFR        (EGFR⁺),    -   (d) patients previously treated with EGFR inhibitors, such as        gefitinib or erlotinib afatinib, dacomitinib or others wherein        the treatment provides to overcome primary or acquired        resistance to EGFR inhibitors,    -   (e) patients with acquired resistance to treatment with TKIs,        such as gefitinib or erlotinib, afatinib, dacomitinib or others,        wherein the treatment provides to overcome resistance to TKI        treatment,    -   (g) patient populations with primary or acquired resistance        caused by T790M (T790M+), wherein the treatment provides to        prevent or overcome resistance to TKI treatment, and    -   (h) patient populations with primary or acquired resistance not        caused by T790M (T790M-), e.g. by other mechanisms such as MET        oncogene or by unknown origin, wherein the treatment provides to        prevent/overcome resistance to TKI treatment.

More preferred, the following patient populations having one of thecancer indications specified hereinbefore may advantageously be treatedby the method of the invention:

-   -   (c) patients with tumors harboring EGFR mutations in exons 19        and 21 associated with drug sensitivity (i.e., G719X, exon 19        deletion, L858R, L861Q),    -   (e) patients with acquired resistance to treatment with TKIs,        such as gefitinib or erlotinib, afatinib, dacomitinib or others,        wherein the treatment provides to overcome resistance to TKI        treatment,    -   (g) patient populations with primary or acquired resistance        caused by T790M (T790M+), wherein the treatment provides to        prevent or overcome resistance to TKI treatment, and    -   (h) patient populations with primary or acquired resistance not        caused by T790M (T790M-), e.g. by other mechanisms such as MET        oncogene or by unknown origin, wherein the treatment provides to        prevent or overcome resistance to TKI treatment.

Most preferred, the following patient population having one of thecancer indications specified hereinbefore may advantageously be treatedby the method of the invention:

-   -   (h) patient populations with primary or acquired resistance not        caused by T790M (T790M-), e.g. by other mechanisms such as MET        oncogene or by unknown origin, wherein the treatment provides to        prevent or overcome resistance to TKI treatment.

Particularly preferred, the following patient population having one ofthe cancer indications specified hereinbefore may advantageously betreated by the method of the invention:

-   -   (h′) patient populations with acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the treatment provides to overcome        resistance to TKI treatment.

Irreversible TKIs suitable with regard to any aspects of the inventioninclude, without limitation, EKB-569 (pelitinib), HKI-272 (neratinib),HKI-357, CI-1033, BIBW 2992 or PF-00299804, and any salts, preferablypharmaceutically acceptable salts, hydrates or solvates thereof,including polymorphs. Preferred TKIs are BIBW 2992 and PF-00299804. Mostpreferred is BIBW 2992.

As a further alternative irreversible TKIs suitable with regard to anyaspects of the invention include1-(4-(4-(3,4-dichloro-2-fluorophenylamino)-7-methoxyquinazolin-6-yloxy)piperidin-1-yl)prop-2-en-1-one,WZ 3146, WZ 4002, WZ 8040, and any salts, preferably pharmaceuticallyacceptable salts, hydrates or solvates thereof, including polymorphs.

MABs suitable with regard to any aspects of the invention include,without limitation, cetuximab, panitumumab, zalutumumab, nimotuzumab,and matuzumab. Preferred mABs are cetuximab and panitumumab. Mostpreferred is cetuximab. A further mABs suitable with regard to anyaspects of the invention is necitumumab.

Any of the irreversible TKIs and any of the mABs mentioned in thecontext of the invention may be combined with each other with regard tothe specified aspects of the invention.

Specific combinations suitable with regard to all aspects of theinvention are

EKB-569/cetuximab, EKB-569/panitumumab, EKB-569/zalutumumab,EKB-569/nimotuzumab, EKB-569/matuzumab,HKI-272/cetuximab, HKI-272/panitumumab, HKI-272/zalutumumab,HKI-272/nimotuzumab, HKI-272/matuzumab, HKI-272/necitumumab,HKI-357/cetuximab, HKI-357/panitumumab, HKI-357/zalutumumab,HKI-357/nimotuzumab, HKI-357/matuzumab,CI-1033/cetuximab, CI-1033/panitumumab, CI-1033/zalutumumab,CI-1033/nimotuzumab, CI-1033/matuzumab,BIBW 2992/cetuximab, BIBW 2992/panitumumab, BIBW 2992/zalutumumab, BIBW2992/nimotuzumab, BIBW 2992/matuzumab, BIBW 2992/necitumumab,PF-00299804/cetuximab, PF-00299804/panitumumab, PF-00299804/zalutumumab,PF-00299804/nimotuzumab, PF-00299804/necitumumab, andPF-00299804/matuzumab.

Preferred combinations of the irreversible TKIs and the mABs suitablewith regard to all aspects of the invention are

HKI-272/cetuximab, HKI-272/panitumumab, HKI-272/zalutumumab,HKI-272/nimotuzumab, HKI-272/matuzumab,BIBW 2992/cetuximab, BIBW 2992/panitumumab, BIBW 2992/zalutumumab, BIBW2992/nimotuzumab, BIBW 2992/matuzumab,PF-00299804/cetuximab, PF-00299804/panitumumab, PF-00299804/zalutumumab,PF-00299804/nimotuzumab, and PF-00299804/matuzumab.

More preferred combinations of the irreversible TKIs and the mABssuitable with regard to all aspects of the invention are

HKI-272/cetuximab, HKI-272/panitumumab,

BIBW 2992/cetuximab, BIBW 2992/panitumumab,

PF-00299804/cetuximab, and PF-00299804/panitumumab.

Most preferred combinations of the irreversible TKIs and the mABssuitable with regard to all aspects of the invention are

BIBW 2992/cetuximab, BIBW 2992/panitumumab,

PF-00299804/cetuximab, and PF-00299804/panitumumab,

specifically preferred is BIBW 2992/cetuximab.

The expressions “prevention”, “prophylaxis”, “prophylactic treatment” or“preventive treatment” used herein should be understood synonymous andin the sense that the risk to develop a condition mentioned herein isreduced. The expression “prevention or delay of resistance” or “toovercome resistance” in the context of the invention means thatdevelopment of resistance to TKI treatment is either avoided or onset ofresistance is delayed or already existing (primary or acquired)resistance is overcome by the combination treatment regimen of theinvention, reflected statistically by reduced incidence or later onsetof resistance within a first patient population treated with acombination treatment regimen according to the invention, in comparisonto an equivalent second patient population receiving parallel treatmentbut without the Human EGFR targeted monoclonal antibody component.

Resistance to TKI or EGFR inhibitor treatment means that the patientdoes not show a response to the treatment. This includes primaryresistance of TKI naive patients when treated for the first time with aTKI, and acquired resistance of patients showing response under TKItreatment for a certain period of time but then progression of thedisease again.

Furthermore, prevention or delay of resistance to TKI treatment meansthat the patients of the first patient population show response underthe combination treatment regimen according to the invention eithercontinuously or for a longer period of time, compared to the secondpatient population. Treatment response and progression of the diseaseare evaluated under the criteria laid down in the revised RECISTguideline (version 1.1). Eur J Cancer 2009;45:228-247 mentionedhereinbefore.

A preferred embodiment of the first object of the present invention is amethod of treating patients suffering from NSCLC, HNSCC, malignantglioma, breast cancer, esophageal cancer, gastric cancer, renal cancer,cervical cancer, prostate cancer, ovarian cancer, pancreatic cancer,hepatocellular cancer or CRC, including metastatic forms thereof,wherein in this method

-   -   a TKI selected from the group consisting of EKB-569, HKI-272,        HKI-357, CI-1033, BIBW 2992 and PF-00299804, or a        pharmaceutically acceptable salt thereof, is administered        according to a continuous regimen based on an average daily dose        in the range of 10 to 50 mg and    -   a mAB selected from the group consisting of cetuximab,        panitumumab, zalutumumab, nimotuzumab and matuzumab is        co-administered according to a dosing regimen ranging from an        average weekly iv dose of 50 to 500 mg/m² repeated thrice, twice        or once a week, once in two weeks, once in three weeks or at        least once monthly to    -   (c) a patient with a tumor expressing mutated forms of the EGFR,        or    -   (d) a patient previously treated with EGFR inhibitors, such as        gefitinib or erlotinib afatinib, dacomitinib or others wherein        the method provides to overcome primary or acquired resistance        to EGFR inhibitors,    -   (e) a patient with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary or acquired resistance caused by        T790M (T790M+), wherein the method provides to prevent or        overcome resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment.

A further preferred embodiment of the first object of the presentinvention is a method of treating patients suffering from NSCLC, HNSCC,malignant glioma, breast cancer or CRC, including metastatic formsthereof, wherein in this method

-   -   a TKI selected from the group consisting of HKI-272, BIBW 2992        and PF-00299804, (BIBW 2992 and PF-00299804 being especially        preferred), or a pharmaceutically acceptable salt thereof, is        administered according to a continuous regimen based on an        average daily dose in the range of 10 to 50 mg and    -   a mAB selected from the group consisting of cetuximab and        panitumumab, is co-administered according to a dosing regimen        ranging from an average weekly iv dose of 50 to 500 mg/m²        repeated twice or once a week or once in two weeks to    -   (c) a patient with a tumor harboring EGFR mutations in exons 19        and 21 associated with drug sensitivity (i.e., G719X, exon 19        deletion, L858R, L861Q), or    -   (e) a patient with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary/acquired resistance caused by T790M        (T790M+), wherein the method provides to prevent or overcome        resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment.

A further preferred embodiment of the first object of the presentinvention is a method of treating patients suffering from NSCLC orHNSCC, including metastatic forms thereof, wherein in this method

-   -   a TKI selected from the group consisting of BIBW 2992 and        PF-00299804 (BIBW 2992 being especially preferred), or a        pharmaceutically acceptable salt thereof, is administered        according to a continuous regimen based on an average daily dose        in the range of 10 to 50 mg and    -   a mAB selected from the group consisting of cetuximab and        panitumumab (cetuximab being especially preferred), is        co-administered according to a dosing regimen ranging from an        average weekly iv dose of 50 to 500 mg/m² repeated twice or once        a week or once in two weeks to    -   (e) a patient with acquired resistance to treatment with TKIs,        such as gefitinib or erlotinib, afatinib, dacomitinib or others,        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary or acquired resistance caused by        T790M (T790M+), wherein the method provides to prevent or        overcome resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to preventer        overcome resistance to TKI treatment.

A further preferred embodiment of the first object of the presentinvention is a method of treating patients suffering from NSCLC,including metastatic forms thereof, wherein in this method

-   -   BIBW 2992, or a pharmaceutical acceptable salt thereof, is        administered according to a continuous regimen based on an        average daily dose in the range of 10 to 50 mg and cetuximab is        is co-administered according to a dosing regimen ranging from an        average weekly iv dose of 50 to 500 mg/m² repeated twice or once        a week to    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment,    -   but most preferably to    -   (h′) a patient with acquired resistance not caused by T790M        (T790M-), e.g. by other mechanisms such as MET oncogene or by        unknown origin, wherein the method provides to overcome        resistance to TKI treatment.

A first preferred embodiment of the second object of the invention is apharmaceutical kit, wherein the second compartment comprises aneffective amount of a TKI selected from the group consisting of EKB-569(pelitinib), HKI-272 (neratinib), HKI-357, CI-1033, BIBW 2992 andPF-00299804 or a pharmaceutically acceptable salt thereof.

A second preferred embodiment of the second object of the invention is apharmaceutical kit, wherein the second compartment comprises aneffective amount of a mAB selected from the group consisting ofcetuximab, panitumumab, zalutumumab, nimotuzumab and matuzumab.

A second preferred embodiment of the second object of the invention is apharmaceutical kit, wherein the second compartment comprises aneffective amount of a mAB selected from the group consisting ofcetuximab, panitumumab, zalutumumab, nimotuzumab and matuzumab.

A third preferred embodiment of the second object of the invention is apharmaceutical kit, comprising a first compartment which comprises aneffective amount of a mAB selected from the group consisting ofcetuximab and panitumumab, and a second compartment which comprises aneffective amount of a TKI selected from the group consisting of HKI-272,BIBW 2992 and PF-00299804, (BIBW 2992 and PF-00299804 being especiallypreferred), or a pharmaceutically acceptable salt thereof.

A fourth preferred embodiment of the second object of the invention is apharmaceutical kit, comprising a first compartment which comprises aneffective amount of a mAB selected from the group consisting ofcetuximab and panitumumab (cetuximab being especially preferred), and asecond compartment which comprises an effective amount of a TKI selectedfrom the group consisting of BIBW 2992 and PF-00299804 (BIBW 2992 beingespecially preferred), or a pharmaceutically acceptable salt thereof.

A fifth preferred embodiment of the second object of the invention is apharmaceutical kit, comprising a first compartment which comprises aneffective amount of cetuximab, and a second compartment which comprisesan effective amount of BIBW 2992, or a pharmaceutically acceptable saltthereof.

A first preferred embodiment of the third object of the invention is anirreversible TKI for use in a method of treatment of a patient sufferingfrom NSCLC, HNSCC, malignant glioma, breast cancer, esophageal cancer,gastric cancer, renal cancer, cervical cancer, prostate cancer, ovariancancer, pancreatic cancer, hepatocellular cancer or CRC, includingmetastatic forms thereof, by coadministration with a Human EGFR targetedmAB,

-   -   wherein the TKI is selected from the group consisting of        EKB-569, HKI-272, HKI-357, CI-1033, BIBW 2992 and PF-00299804,        or a pharmaceutically acceptable salt thereof, and is        administered according to a continuous regimen based on an        average daily dose in the range of 10 to 50 mg, and    -   the mAB is selected from the group consisting of cetuximab,        panitumumab, zalutumumab, nimotuzumab and matuzumab and is        co-administered according to a dosing regimen ranging from an        average weekly iv dose of 50 to 500 mg/m² repeated thrice, twice        or once a week, once in two weeks, once in three weeks or at        least once monthly to    -   (c) a patient with a tumor expressing mutated forms of the EGFR,        or    -   (d) a patient previously treated with EGFR inhibitors, such as        gefitinib or erlotinib afatinib, dacomitinib or others wherein        the method provides to overcome primary or acquired resistance        to EGFR inhibitors,    -   (e) a patient with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary or acquired resistance caused by        T790M (T790M+), wherein the method provides to prevent or        overcome resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment.

A second preferred embodiment of the third object of the invention is anirreversible TKI for use in a method of treatment of a patient sufferingfrom NSCLC, HNSCC, malignant glioma, breast cancer or CRC, includingmetastatic forms thereof, wherein in this method

-   -   the TKI is selected from the group consisting of HKI-272, BIBW        2992 and PF-00299804, (BIBW 2992 and PF-00299804 being        especially preferred), or a pharmaceutically acceptable salt        thereof, and is administered according to a continuous regimen        based on an average daily dose in the range of 10 to 50 mg, and    -   the mAB is selected from the group consisting of cetuximab and        panitumumab, and is co-administered according to a dosing        regimen ranging from an average weekly iv dose of 50 to 500        mg/m² repeated twice or once a week or once in two weeks to    -   (c) a patient with a tumor harboring EGFR mutations in exons 19        and 21 associated with drug sensitivity (i.e., G719X, exon 19        deletion, L858R, L861Q), or    -   (e) a patient with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary/acquired resistance caused by T790M        (T790M+), wherein the method provides to prevent or overcome        resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment.

A third preferred embodiment of the third object of the invention is anirreversible TKI for use in a method of treatment of a patient sufferingfrom NSCLC or HNSCC, including metastatic forms thereof, wherein in thismethod

-   -   the TKI is selected from the group consisting of BIBW 2992 and        PF-00299804 (BIBW 2992 being especially preferred), or a        pharmaceutically acceptable salt thereof, is administered        according to a continuous regimen based on an average daily dose        in the range of 10 to 50 mg, and    -   the mAB is selected from the group consisting of cetuximab and        panitumumab (cetuximab being especially preferred), and is        co-administered according to a dosing regimen ranging from an        average weekly iv dose of 50 to 500 mg/m² repeated twice or once        a week or once in two weeks to    -   (e) a patient with acquired resistance to treatment with TKIs,        such as gefitinib or erlotinib, afatinib, dacomitinib or others,        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary or acquired resistance caused by        T790M (T790M+), wherein the method provides to prevent or        overcome resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to preventer        overcome resistance to TKI treatment.

A fourth preferred embodiment of the third object of the invention is anirreversible TKI for use in a method of treatment of a patient sufferingfrom NSCLC, including metastatic forms thereof, wherein in this method

-   -   the TKI is BIBW 2992, or a pharmaceutical acceptable salt        thereof, and is administered according to a continuous regimen        based on an average daily dose in the range of 10 to 50 mg, and    -   the mAB is cetuximab and is co-administered according to a        dosing regimen ranging from an average weekly iv dose of 50 to        500 mg/m² repeated twice or once a week to    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g.

by other mechanisms such as MET oncogene or by unknown origin, whereinthe method provides to prevent or overcome resistance to TKI treatment,

-   -   but most preferably to    -   (h′) a patient with acquired resistance not caused by T790M        (T790M-), e.g. by other mechanisms such as MET oncogene or by        unknown origin, wherein the method provides to overcome        resistance to TKI treatment.

In a first preferred embodiment of the fourth object of the inventionthe irreversible tyrosine kinase inhibitor (TKI) is selected from thegroup consisting of EKB-569 (pelitinib), HKI-272 (neratinib), HKI-357,CI-1033, BIBW 2992 and PF-00299804 or a pharmaceutically acceptable saltthereof.

In a second preferred embodiment of the fourth object of the inventionthe Human EGFR targeted monoclonal antibody (mAB) is selected from thegroup consisting of cetuximab, panitumumab, zalutumumab, nimotuzumab,and matuzumab.

In a third preferred embodiment of the fourth object of the inventionthe cancer is selected from the group consisting of NSCLC, HNSCC,malignant glioma, breast cancer, esophageal cancer, gastric cancer,renal cancer, cervical cancer, prostate cancer, ovarian cancer,pancreatic cancer, hepatocellular cancer and CRC, including metastaticforms thereof,

-   -   the TKI is selected from the group consisting of EKB-569,        HKI-272, HKI-357, CI-1033, BIBW 2992 and PF-00299804, or a        pharmaceutically acceptable salt thereof,    -   the mAB is selected from the group consisting of cetuximab,        panitumumab, zalutumumab, nimotuzumab and matuzumab, and    -   the patient is    -   (c) a patient with a tumor expressing mutated forms of the EGFR,        or    -   (d) a patient previously treated with EGFR inhibitors, such as        gefitinib or erlotinib afatinib, dacomitinib or others wherein        the method provides to overcome primary or acquired resistance        to EGFR inhibitors,    -   (e) a patient with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary or acquired resistance caused by        T790M (T790M+), wherein the method provides to prevent or        overcome resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment.

In a fourth preferred embodiment of the fourth object of the inventionthe cancer is selected from the group consisting of NSCLC, HNSCC,malignant glioma, breast cancer and CRC, including metastatic formsthereof,

-   -   the TKI is selected from the group consisting of HKI-272, BIBW        2992 and PF-00299804, (BIBW 2992 and PF-00299804 being        especially preferred), or a pharmaceutically acceptable salt        thereof,    -   the mAB is selected from the group consisting of cetuximab and        panitumumab, and is co-administered according to a dosing        regimen ranging from an average weekly iv dose of 50 to 500        mg/m² repeated twice or once a week or once in two weeks to, and    -   the patient is    -   (c) a patient with a tumor harboring EGFR mutations in exons 19        and 21 associated with drug sensitivity (i.e., G719X, exon 19        deletion, L858R, L861Q), or    -   (e) a patient with acquired resistance to treatment with TKIs        such as gefitinib or erlotinib, afatinib, dacomitinib or others        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary/acquired resistance caused by T790M        (T790M+), wherein the method provides to prevent or overcome        resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment.

In a fifth preferred embodiment of the fourth object of the inventionthe cancer is selected from the group consisting of NSCLC or HNSCC,including metastatic forms thereof,

-   -   the TKI is selected from the group consisting of BIBW 2992 and        PF-00299804 (BIBW 2992 being especially preferred), or a        pharmaceutically acceptable salt thereof,    -   the mAB is selected from the group consisting of cetuximab and        panitumumab (cetuximab being especially preferred), and    -   the patient is    -   (e) a patient with acquired resistance to treatment with TKIs,        such as gefitinib or erlotinib, afatinib, dacomitinib or others,        wherein the method provides to overcome resistance to TKI        treatment,    -   (g) a patient with primary or acquired resistance caused by        T790M (T790M+), wherein the method provides to prevent or        overcome resistance to TKI treatment, or    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to preventer        overcome resistance to TKI treatment.

In a sixth preferred embodiment of the fourth object of the inventionthe cancer is NSCLC, including metastatic forms thereof,

-   -   the TKI is BIBW 2992, or a pharmaceutical acceptable salt        thereof,    -   the mAB is cetuximab and is co-administered according to a        dosing regimen ranging from an average weekly iv dose of 50 to        500 mg/m² repeated twice or once a week to    -   (h) a patient with primary or acquired resistance not caused by        T790M (T790M-), e.g. by other mechanisms such as MET oncogene or        by unknown origin, wherein the method provides to prevent or        overcome resistance to TKI treatment,

In a seventh preferred embodiment of the fourth object of the invention

-   -   (h′) the patient has acquired resistance not caused by T790M        (T790M-), e.g. by other mechanisms such as MET oncogene or by        unknown origin, wherein the method provides to overcome        resistance to TKI treatment.

Dosages/Irreversible TKI:

Dosage forms of the irreversible TKIs are either available on the marketor described in publications. According to any aspect of the inventionthe TKI, e.g. BIBW 2992, is administered in a total average daily doseof 10 to 50 mg, e.g. in a total average daily dose selected from 10, 15,20, 25, 30, 35, 40, 45 and 50 mg, optionally divided into multipledoses, e.g. 1, 2 or 3 doses to be administered through the day.Preferably the TKI is administered orally only once a time per day, butalternative routes of administration may be applied.

Dosages/mABs:

Dosage forms of the mABs also are either available on the market ordescribed in publications. According to any aspect of the inventionaverage weekly iv doses of 50 to 500 mg/m², e.g. 50, 75, 100, 200, 250,300, 350, 375, 400, 425, 450, 475 and 500 mg/m² of the mAB component,e.g. cetuximab or panitumumab, may be applied in the regimen mentionedin the context of the invention.

Based on body weight single iv doses of 1 to 15 mg/kg, e.g. 1, 1.5, 2,2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5,11, 11.5, 12, 12.5, 13, 13.5, 14, 14.5 or 15 mg/kg of the mAB component,e.g. cetuximab or panitumumab, may be applied in the regimen mentionedin the context of the invention. Based on a 70 kg adult patient thisresults in 70 to 1050 mg range for a single dose.

However, it may optionally be necessary to deviate from the dosageamounts specified for the TKI and/or the mAB component, within thelimitations set, depending on the body weight or method ofadministration, the individual response to the medication, the nature ofthe formulation used and the time or interval over which it isadministered. When dosages at the high end are administered it may beadvisable to spread them over the day in a number of single doses.

Instruction for Coadministration:

Instructions for coadministration may be in any form suitable forpharmaceuticals, e.g. in form of a leaflet added to the dosage formwithin secondary packaging or an imprint on the primary or secondarypackaging.

The following Example serve to illustrate the invention withoutrestricting it:

Example 1: Activity and Tolerability of Afatinib (BIBW 2992; A) andCetuximab (C) in Patients with Non-Small Cell Lung Cancer (NSCLC) andAcquired Resistance to Erlotinib (E) or Gefitinib (G)(ClinicalTrials.gov identifier: NCT01090011) Background:

Despite initial responses to reversible EGFR-TKIs e.g. E or G, all NSCLCpatients with EGFR sensitizing mutations experience disease progression.This “acquired resistance” (AR) is associated with a second site exon 20EGFR T790M mutation (M) in over half of cases. So far, no therapy,including the anti-EGFR antibody C plus E, has proven effective intreating AR (Janjigian Y Y. Clin Cancer Res; Epub January 2011).Preclinical data suggest that A, a potent irreversible inhibitor of theErbB receptor family, is active in M cell lines. Combined EGFR targetingwith A and C has induced near complete responses in T790M transgenicmurine models. This is the first clinical study to assess safety andpreliminary efficacy of this combination in NSCLC patients.

Methods:

NSCLC patients with clinically defined AR (Jackman D. J Clin Oncol 2010;28:357) received oral A 40 mg daily with escalating dose cohorts ofbiweekly C at 250 and 500 mg/m². Patients receiving the recommendedphase 2 dose (RP2D) were evaluated for objective response. Acquisitionof tumor tissue at or after emergence of AR was mandated.

Results:

Of 26 treated patients, 22 received the pre-defined maximum dose=RP2D: A40 mg+C 500 mg/m². Median time on E or G at study entry was 2.4 years.No dose-limiting toxicity was observed. The common adverse events (AE)were rash (83%) and diarrhea (62%). 3 (6.4%) patients had grade 3 rashand 2 (4.3%) patients had grade 3 diarrhea. Disease control was observedin all patients enrolled at RP2D (tumor size reduction up to 76%,treatment duration up to 5+ months). Confirmed partial responses (PRs)were seen in 12/32 (38%) evaluable patients, including 10/17 (59%) and6/55 (14%) not (yet) confirmed PRs in T790M+ and T790M-NSCLC,respectively.

Overall results regarding tolerability (adverse events) and treatmentresponse are summarized in tables 1 and 2.

CONCLUSIONS

Combined EGFR targeting with A and C is tolerable at the RP2D. Mild tomoderate diarrhea and skin adverse events are manageable. Diseasecontrol was observed in all patients enrolled at RP2D. EGFRmut+ NSCLCwith AR to erlotinib and gefitinib continues to depend on EGFRsignaling. A in combination with C overcomes acquired resistance toprior erlotinib/gefitinib. The clinical activity is not restricted toT790M mediated acquired resistance.

1. A method of treating a patient suffering from cancer driven byderegulated Human Epidermal Growth Factor Receptor (HER/Human EGFR),which cancer is selected from the group consisting of head and necksquamous cell carcinoma (HNSCC), malignant glioma, breast cancer,esophageal cancer, gastric cancer, renal cancer, cervical cancer,prostate cancer, ovarian cancer, pancreatic cancer, hepatocellularcancer, and colorectal cancer (CRC), including metastatic forms thereof,and wherein: the patient has a tumor expressing mutated forms of theEGFR, and the patient has acquired resistance to tyrosine kinaseinhibitor (TKI) treatment, comprising administering to a patient in needof such treatment a flexible and active regimen for combining anirreversible tyrosine kinase inhibitor (TKI) and a Human EGFR targetedmonoclonal antibody (mAB), wherein in this method the TKI isadministered according to a continuous regimen based on an average dailydose in the range of 10 to 50 mg and the mAB is co-administeredaccording to a dosing regimen ranging from an average weekly iv dose of50 to 500 mg/m² repeated thrice, twice or once a week, once in twoweeks, once in three weeks or at least once monthly wherein the methodresults in overcoming the acquired resistance to tyrosine kinaseinhibitor (TKI) treatment. 2-7. (canceled)
 8. The method of claim 1,wherein the cancer is selected from the group consisting of NSCLC,HNSCC, malignant glioma, breast cancer, esophageal cancer, gastriccancer, renal cancer, cervical cancer, prostate cancer, ovarian cancer,pancreatic cancer, hepatocellular cancer or CRC, including metastaticforms thereof, the TKI is selected from the group consisting of HKI-272,BIBW 2992 and PF-00299804, or a pharmaceutically acceptable saltthereof, and is administered according to a continuous regimen based onan average daily dose in the range of 10 to 50 mg, the mAB is selectedfrom the group consisting of cetuximab, panitumumab, zalutumumab,nimotuzumab and matuzumab and is co-administered according to a dosingregimen ranging from an average weekly iv dose of 50 to 500 mg/m²repeated thrice, twice or once a week, once in two weeks, once in threeweeks or at least once monthly to: a patient with a tumor expressingmutated forms of the EGFR, and with acquired resistance to TKI treatmentwherein the method results in overcoming the acquired resistance totyrosine kinase inhibitor (TKI) treatment.
 9. The method of claim 1,wherein the cancer is selected from the group consisting of HNSCC,malignant glioma, breast cancer or CRC, including metastatic formsthereof, the TKI is selected from the group consisting of BIBW 2992 andPF-00299804,), or a pharmaceutically acceptable salt thereof, and isadministered according to a continuous regimen based on an average dailydose in the range of 10 to 50 mg, the mAB is selected from the groupconsisting of cetuximab and panitumumab, and is co-administeredaccording to a dosing regimen ranging from an average weekly iv dose of50 to 500 mg/m² repeated twice or once a week or once in two weeks to: apatient with a tumor harboring EGFR mutations in exons 19 and 21associated with drug sensitivity (i.e., G719X, exon 19 deletion, L858R,L861Q), and with acquired resistance to TKI treatment wherein the methodresults in overcoming the acquired resistance to tyrosine kinaseinhibitor (TKI) treatment.
 10. The method of claim 1, wherein the canceris HNSCC, including metastatic forms thereof, the TKI is selected fromthe group consisting of BIBW 2992 and PF-00299804, or a pharmaceuticallyacceptable salt thereof, and is administered according to a continuousregimen based on an average daily dose in the range of 10 to 50 mg, themAB is selected from the group consisting of cetuximab and panitumumab,and is co-administered according to a dosing regimen ranging from anaverage weekly iv dose of 50 to 500 mg/m² repeated twice or once a weekor once in two weeks to a patient with acquired resistance to treatmentwith TKIs, such as gefitinib or erlotinib, afatinib, dacomitinib orothers, wherein the method provides to overcome resistance to TKItreatment.
 11. The method of claim 1, wherein the cancer is HNSCC orCRC, including metastatic forms thereof, the TKI is BIBW 2992, or apharmaceutical acceptable salt thereof, and is administered according toa continuous regimen based on an average daily dose in the range of 10to 50 mg, the mAB is cetuximab and is co-administered according to adosing regimen ranging from an average weekly iv dose of 50 to 500 mg/m²repeated twice or once a week to (h) a patient with primary or acquiredresistance not caused by T790M (T790M-), wherein the method results inovercoming resistance to TKI treatment.
 12. (canceled)
 13. Apharmaceutical kit, comprising a first compartment which comprises aneffective amount of a Human EGFR targeted mAB and a second compartmentwhich comprises an effective amount of an irreversible TKI.
 14. Thepharmaceutical kit of claim 13, wherein the irreversible tyrosine kinaseinhibitor (TKI) is selected from the group consisting of EKB-569(pelitinib), HKI-272 (neratinib), HKI-357, CI-1033, BIBW 2992 andPF-00299804 or a pharmaceutically acceptable salt thereof.
 15. Thepharmaceutical kit of claim 13, wherein the TKI is selected from thegroup consisting of1-(4-(4-(3,4-dichloro-2-fluorophenylamino)-7-methoxyquinazolin-6-yloxy)piperidin-1-yl)prop-2-en-1-one,WZ 3146, WZ 4002, and WZ 8040, or a pharmaceutical acceptable saltthereof.
 16. The pharmaceutical kit of claim 14, wherein the Human EGFRtargeted monoclonal antibody (mAB) is selected from the group consistingof cetuximab, panitumumab, zalutumumab, nimotuzumab, and matuzumab. 17.The pharmaceutical kit of claim 14 wherein the Human EGFR targetedmonoclonal antibody (mAB) is necitumumab.
 18. The method of claim 1,wherein (g) the patient has acquired resistance caused by T790M(T790M+), and the method results in overcoming resistance to TKItreatment, or (h) the patient has acquired resistance not caused byT790M (T790M-), and the method results in overcoming resistance to TKItreatment.
 19. The method of claim 1, wherein (h) the patient hasacquired resistance not caused by T790M (T790M-), and the method resultsin overcoming resistance to TKI treatment.
 20. The method of claim 19,wherein the irreversible tyrosine kinase inhibitor (TKI) is selectedfrom the group consisting of EKB-569 (pelitinib), HKI-272 (neratinib),HKI-357, CI-1033, BIBW 2992 and PF-00299804 or a pharmaceuticallyacceptable salt thereof.
 21. The method of claim 19, wherein the TKI isselected from the group consisting of1-(4-(4-(3,4-dichloro-2-fluorophenylamino)-7-methoxyquinazolin-6-yloxy)piperidin-1-yl)prop-2-en-1-one,WZ 3146, WZ 4002, and WZ 8040, or a pharmaceutical acceptable saltthereof.
 22. The method of claim 20, wherein the Human EGFR targetedmonoclonal antibody (mAB) is selected from the group consisting ofcetuximab, panitumumab, zalutumumab, nimotuzumab and matuzumab.
 23. Themethod of claim 20, wherein the Human EGFR targeted monoclonal antibody(mAB) is necitumumab.
 24. The method of claim 8, wherein the acquiredresistance to TKI treatment is acquired resistance of gefitinib,erlotinib, afatinib or dacomitinib treatment.
 25. The method of claim 9,wherein the acquired resistance to TKI treatment is acquired resistanceof gefitinib, erlotinib, afatinib or dacomitinib treatment.
 26. Themethod of claim 11, wherein the acquired resistance not caused by T790M(T790M-) is caused by a MET oncogene mechanism or mechanism of unknownorigin.
 27. The method of claim 1, wherein: the TKI is selected from thegroup consisting of EKB-569 (pelitinib), HKI-272 (neratinib), HKI-357,CI-1033, BIBW 2992, PF-00299804,1-(4-(4-(3,4-dichloro-2-fluorophenylamino)-7-methoxyquinazolin-6-yloxy)piperidin-l-yl)prop-2-en-l-one,WZ 3146, WZ 4002 and WZ 8040, or a pharmaceutically acceptable saltthereof, and the mAB is selected from the group consisting of cetuximab,panitumumab, zalutumumab, nimotuzumab and matuzumab.